Ordering ward stock

Ordering ward stock

Nurse requisitioning

Safety and security are key issues here. Ward staff tend to accept that what is supplied by pharmacy is correct, even though the supply may be based on an ambiguous or poorly written requisition, without sight of the prescription. On occasion, nursing staff may even identify an error made in the pharmacy department, but assume that because it has come from pharmacy, it is the correct product.

Traditionally, pharmacy would make a supply to patients on the strength of a requisition alone. One of the drivers for the development of clinical pharmacy was to encourage the review of prescriptions by a pharmacist in order to keep prescription and administration charts on wards, where they are in constant clinical use. An additional incentive was that it was easier to address problems with prescriptions at ward level in conjunction with the patient and the nursing and medical staff than it is in isolation in a pharmacy dispensary. More recently, most hospitals will not dispense an item without sight of the prescription chart and a check by a clinical pharmacist at ward level or in the dispensary. CDs are discussed in Chapter 5.

Topping up

Responsibility for routine ordering of ward stock is transferred, under this system, from nursing staff to pharmacy technicians or assistants, who check and replenish this to predetermined levels, usually weekly or twice weekly depending on the storage capacity and turnover of the wards concerned. The requirements are entered on either a computer-printed copy of the ward stock list or one stored on a hand-held computer, for example a personal digital assistant or bar code-scanning device. The stock list should be based on usage and agreed between the appointed nurse and a designated member of pharmacy staff, usually a technician, while clinical input from a pharma-cist is also essential. The content of a ward stock list should be a balance between having readily available supplies of commonly used medicines and trying to cover every eventuality, which means stock lists which are greater than ward storage capacity allows and will probably result in stock items unnecessarily going out of date. Supplies are usually dispatched to the ward, in locked boxes, for nursing staff to put away and store. A delivery note recording what has been supplied should be sent to the ward with the products requested, and a copy should be retained in pharmacy once it has been signed by the nursing staff on the ward to confirm receipt. The top-up system is useful because it allows planning of workload, and reduces the need for nursing staff to spend significant amounts of time ordering medicines and the likelihood of commonly used medicines not being avail-able to patients who need them.

Supply to outpatients

A number of options are available to allow patients access to medicines following an outpatient consultation in a hospital. The reason that these options exist arises from perverse arrangements for funding outpatient pre-scribing, and the application of value-added tax (VAT) to hospital-dispensed medicines, but not to those dispensed in the community.

Community dispensed route

The advantage to the hospital is that it does not pay VAT on medicines prescribed via this route; patients can be seen in clinic and then leave the hospital and go to their own community pharmacy, or at least one of their own choosing. This route also allows hospital pharmacy resources to be focused on the needs of inpatients and timely discharge processes. The dis-advantages are that it is difficult to police what prescribers are writing on the forms in terms of formulary compliance and quantity, and the information arising from this has a lag time of approximately 3 months while the data are processed and collated by the prescription pricing authority. Another disad-vantage is that prescriptions dispensed via this route do not attract contracted NHS discount prices and, in some cases, this cost differential may exceed that of VAT. In terms of public funding, the VAT reduction for the organisation using this route is matched by a reduction in revenues to the treasury. (Forms used by hospitals for dispensing in the community are known as FP10 in England, WP10 in Wales and GP10 in Scotland; the term has also been suffixed with (HP) to distinguish from GP forms.)

Hospital pharmacy dispensing

Similarly, prescriptions dispensed for outpatients from the hospital pharmacy may be more convenient for patients to collect while in the hospital, and may provide some reassurance to them. Hospitals pay VAT on medicines, whereas dispensing by community pharmacists is zero-rated and advantageous prices obtained through hospital contracts may be insufficient to counterbalance this difference. A major disadvantage to the hospital is that outpatient dis-pensing deflects pharmacists and technicians from a clinical role on the wards. In 1988 the Department of Health, in a health circular requiring health authorities to plan for implementation of clinical pharmacy, suggested that ‘subject to a satisfactory local option-appraisal exercise’, FP10(HP) forms could be used, ‘thereby releasing hospital staff for other duties’. Outpatient dispensing by hospitals is further challenged in the Audit Commission report, which in paragraph 64 suggests that ‘the practice should be questioned’.

Prepacked medicines

Suitably labelled prepacked medicines for standard treatments may be issued to departments (such as accident and emergency or outpatient clinics) for medical or nursing staff to add the patient’s name and minor alterations to directions. Predictable requirements for day-case patients following surgery may be able to be dispensed in advance and issued after the pharmacy has closed. The advantage of this is that a limited list of products is supplied and is available to patients immediately following a consultation. This means that patients are accessing medicines without having to use resources in the hospital pharmacy, possibly bought at contract prices, and they do not have to wait.

GP referral forms

These forms are a benefit to the hospital in that prescribing costs are not picked up by the hospital, but they are inconvenient to patients since, in order to collect their medicines, they need to visit the GP, hand in the form, wait for 24–48 hours while the form is processed, collect the prescription from the GP and then go to the community pharmacy. This is hardly an efficient use of resources or helping the patient experience. The option of referring patients back to their GP for prescribing is dependent on the acceptability of transfer of clinical responsibility.In Scotland the GP always retains this: the out-patient is referred to the hospital only for a consultation, so prescription on GP10 forms is the norm. In England and Wales such transfer of prescribing was often seen as ‘cost-shifting’ of expensive treatments from hospital budgets to primary care. This was unpopular with GPs, when they had insufficient information to manage the patient safely, since ultimate liability lies with the doctor who signs the prescription. These problems can be overcome with shared-care agreements between the consultant and the GP on continuing care, once the patient’s condition is stable, under a protocol normally pro-vided by the hospital. For some patients the GP may prefer to initiate long-term treatment with a drug from the practice formulary.

'RAG lists'

Many areas have a ‘RAG list’ (red, amber, green list) that is a list of medicines suitable for prescribing either in hospitals, or by GPs, or both. For example, most cytotoxic preparations or retinoids would always be ‘red’ and hospital-only prescriptions, whereas antibiotics or antihypertensives would always be ‘green’. There may be exceptions to this general rule, where a new class of drug is introduced or the drug is for a niche indication. ‘Amber’ drugs tend to be medicines that might be initiated by the hospital, and then once the patient is reasonably stable, care would be taken over by the GP via a shared-care protocol, for example, methotrexate.

Home care

Since the late 1990s, the use of home care has expanded enormously. Hospitals enter an arrangement with a home care company, of which there are several, to supply medicines to their patients. The consultant seeing the patient completes a bespoke prescription form that goes to the home care company. The company then supplies the medicines directly to the patient, either by post or by courier, and in some instances will also provide nursing support, including either administering the drug or training patients to do it themselves. Such arrangements should have suitable financial and clinical governance arrangements.

Community pharmacy partnerships

A more recent development is the introduction of independent pharmacies to hospital sites. The model is such that the community pharmacy dispenses outpatient prescriptions from the hospital. The medicines used in the supply to patients are purchased at contract prices which would routinely be avail-able to that hospital, and also dispensed at zero VAT, resulting in potentially significant cost savings to the trust. In this way, hospitals will be able to take advantage of zero-rated VAT and, in addition, receive a double saving via contracted discounts.

Overall, it may be that a number of routes are appropriate for a hospital to make the most of cost-efficient prescribing strategies. For example, when providing antitumour necrosis factor-alpha therapies such as etanercept, where there is no contract price, and VAT is significant, the home care route is attractive. Similarly, the prescription of urgently needed antibiotics or analgesics might best be provided via the FP10 route while supply of anti-retrovirals might be suited to a partnership with a community pharmacy on the hospital site. For extemporaneous preparations, the hospital pharmacy is an appropriate route because of the costs associated with prescription via FP10 and supply via specials manufacturers. However, the complexity of this section highlights the inefficiencies and lack of a seamless approach to the supply of medicines to outpatients.

Clinical trials

A clinical trial is an investigation by a doctor or dentist involving adminis-tration of a medicinal product to a patient to assess the product’s safety and efficacy (a Medicines and Healthcare products Regulatory Agency defini-tion). The pharmacist has a key role in the organisation and management of clinical trials, which is much wider than the supply function; this is reflected in good clinical practice. A definition from EU Directive 2001/20/EC, article 1, clause 2 states that ‘Good clinical practice is a set of internationally recog-nised ethical and scientific quality requirements which must be observed for designing, conducting, recording and reporting clinical trials that involve the participation of human subjects’.

All medicines, or constituent ingredients, for clinical trials should be ordered, stored and dispensed by the hospital pharmacy. Separate stocks should not be kept elsewhere in the hospital. Accurate records must be main-tained of receipt, dispensing, issue, administration and disposal and ‘regularly audited by pharmacy staff, with reconciliation, where necessary’. All staff involved in dispensing clinical trials must have been trained to do so, and record of this training kept in each trial folder. Disposal of unused products in a company-sponsored trial must be according to the company’s instructions.